Fatal incidents investigations
Self-inflicted deaths of IPP prisoners
The Prisons and Probation Ombudsman, Adrian Usher, has today (8 September 2023) published a rather traumatic learning lessons bulletin prompted by the worrying increase in self-inflicted deaths of prisoners serving Imprisonment for Public Protection (IPP) sentences in 2022. The PPO have continued to see self-inflicted deaths of IPP prisoners in 2023.
2022 saw the highest number of self-inflicted deaths among the IPP prison population since
the sentence was introduced. The PPO is clear that more needs to be done by HMPPS to ensure these high levels of self‑inflicted deaths do not continue.
An IPP sentence should be considered as a potential risk factor for suicide and self-harm.
IPP prisoners struggle with their uncertain status leading to feelings of hopelessness and frustration. This can cause a lack of engagement with the parole process and sentence planning and create a lack of trust in the system. It is clear there are several risk triggers associated with IPP prisoners, including parole hearings, recall, prison transfers, change in security categorisation
and upcoming release.
78 IPPs have killed themselves
As of December 2022, there have been 78 IPP self-inflicted deaths, since the sentence was introduced in April 2005, which is 6% of all self‑inflicted deaths during this period. The grap below shows the number of self-inflicted deaths every year between 2005 when the sentence was introduced and 2022.
The bulletin published today focuses on the findings from 19 Prisons and Probation Ombudsman (PPO) investigations into self-inflicted deaths of IPP prisoners between 1 January 2019 and 30 June 2023.
Assessment, Care in Custody and Teamwork (ACCT) management
ACCT is a multi-disciplinary case management approach used in prisons to support people at risk of suicide or self-harm. It focuses on identifying risks and triggers that might increase a person’s risk of suicide and self-harm and provides extra support around these events.
Of the 19 self‑inflicted deaths reviewed for this bulletin, only five of the individuals were on ACCT monitoring at the time of their death. This suggests that more needs to be done to recognise a prisoner’s IPP status as a potential risk factor and to identify the triggers for suicide and self‑harm that are associated with this status.
As well as referring to the harm that an IPP sentence can cause, the Justice Select Committee also referred to the “recall merry go round” in its recent inquiry into IPPs.
Following recall to prison, IPP prisoners are faced again with the uncertainty around their sentence and if they will be released. Due to the licence aspect of the IPP sentence, prisoners can feel that the licence is never ending and therefore the sentence will never fully end. The PPO recommends that staff should be alert to a number of potential triggers for suicide and self-harm, including: parole hearings, recall, prison transfers, recategorisation and return from open conditions.
Key work scheme
The key work scheme is a key part of HMPPS’ response to self-inflicted deaths, self-harm and violence in prisons. The aim is to reduce violence and self-harm in prisons by developing better relationships between staff and prisoners. Under the key work scheme, every male prisoner (in the closed prison estate) should have a dedicated prison officer key worker with whom they have weekly 1-1 contact.
Key work is only delivered in the closed male prison estate and to eligible women in the female estate. Not all women receive key work and key work is not delivered in the open male estate.
We have found that the key work scheme is not operating as anticipated in all prisons due to factors including, staffing shortages and some prisons prioritising the most vulnerable prisoners for the key work sessions.
The Ombudsman cites two cases of IPP prisoners who took their own lives for whom key work was not consistently provided.
Setbacks in sentence progression can increase a prisoner’s risk of suicide and self-harm. Insufficient opportunities to participate in offending behaviour programmes can increase frustrations and create a sense of hopelessness, particularly for those serving an IPP sentence who may need access to interventions to help address outstanding risk factors and demonstrate their risk has reduced to a level where it can be managed in the community. The case of another individual (Mr D in the report) demonstrates not only how a lack of access to offending behaviour programmes can cause frustrations, but it also highlights another significant trigger – ongoing police investigations and potential for further charges.
The PPO does not directly speculate on what appears to be a high number of people on IPPs taking their own lives since the Government rejected the Justice Committee’s recommendation that all IPPs should be resentenced in February this year.